MEDICARE: CHOICE FAMILY MEDICAL CLINIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	261QP2300X	Primary Care Clinic/Center
2	261QU0200X	Urgent Care Clinic/Center
3	261Q00000X	Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	NV20201837431	OTHER	NV	STATE OF NEVADA

General Provider Information

NPI Number	:	1538778634
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHOICE FAMILY MEDICAL CLINIC LLC

Provider Business Mailing Address
First Line	:	400 N STEPHANIE ST STE 260
Second Line	:
City	:	HENDERSON
State	:	NV
Zip	:	89014-6800
Country	:	US
Telephone Number	:	702-629-5555
Fax Number	:

Provider Business Practice Location Address
First Line	:	4185 VEGAS VALLEY DR STE C
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89121-2522
Country	:	US
Telephone Number	:	702-463-9066
Fax Number	:	702-463-9067

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. LETANIYA WARREN TATUM
Credential	:
Telephone Number	:	702-680-0600

Provider Enumeration Date	:	07/24/2020
Last Update Date	:	04/06/2022

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Directions to “CHOICE FAMILY MEDICAL CLINIC LLC ” Practice Location

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